Combined IM/GI residency?

[Merely]

Is it possible to apply as an M4 to an IM residency program that will guarantee you with a GI fellowship position? I feel like that would be pretty sweet if you know you're set on GI as a medical student rather than having to do 3 years of IM and possibly not getting into GI then getting screwed for the rest of your career. Any thoughts?

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[gutonc]

Is it possible to apply as an M4 to an IM residency program that will guarantee you with a GI fellowship position? I feel like that would be pretty sweet if you know you're set on GI as a medical student rather than having to do 3 years of IM and possibly not getting into GI then getting screwed for the rest of your career. Any thoughts?

No. There are research pathway programs, but you have to have a good reason to be doing one of these (like a PhD and a significant research CV), not just "I want to make sure I get a Cards/GI/Hem-Onc fellowship spot".

If you plan to quit medicine if you don't get a GI fellowship, you should probably think about another specialty.

 

[Merely]

That some bull**** though lol like why would they make it so that you're forced to go into something you don't really like in order to get something you want but have to risk being completely ****ed and being forced to stay in internal medicine?

 

[rokshana]

That some bull**** though lol like why would they make it so that you're forced to go into something you don't really like in order to get something you want but have to risk being completely ****ed and being forced to stay in internal medicine?

ummm, i don't know...maybe because IM is the CORE specialty that is the backbone of any medicine subspecialty...

maybe you should have gone the PA/NP route if you are in such a rush.

 

[ShuperNewbie]

ummm, i don't know...maybe because IM is the CORE specialty that is the backbone of any medicine subspecialty...

maybe you should have gone the PA/NP route if you are in such a rush.

This. Much of GI isn't even procedural (e.g. managing IBD/cirrhosis is fundamentally medical with procedural aspects involved). Most well regarded IM programs have 100% or near 100% match in GI, but what I'm trying to get at is that if you really hate medicine that much then honestly, you should probably be considering alternatives. If it could be done without medicine, they would've done it already.

 

[gutonc]

That some bull**** though lol like why would they make it so that you're forced to go into something you don't really like in order to get something you want but have to risk being completely ****ed and being forced to stay in internal medicine?

Because it's not all scoping fo' dollahs yo!

"F***ed and forced to stay in internal medicine"? You know what man...**** that. Seriously. Let us know how the derm match works out for you. I assure that nobody in IM, or GI, wants you if this is your attitude.

 

[bronx43]

Lol, kid's got a bad attitude, sure. But, he brings up a salient point in terms of the redundancy of medical education. The idea that you NEED 3 years of IM in order to do many of the subspecialties is just pure non-sense. Intern year is a must obviously, and you can make a reasonable argument for second year, but third year? Hell nah.

Honestly, you can make the same or even better argument for the redundancy of 90% of medical school for many of the surgical fields.

 

[PlutoBoy]

Lol, kid's got a bad attitude, sure. But, he brings up a salient point in terms of the redundancy of medical education. The idea that you NEED 3 years of IM in order to do many of the subspecialties is just pure non-sense. Intern year is a must obviously, and you can make a reasonable argument for second year, but third year? Hell nah.

Honestly, you can make the same or even better argument for the redundancy of 90% of medical school for many of the surgical fields.

Preach. We need to revamp the way we train our doctors. So much wasted time.

 

[1Cor1557]

even the combo physician scientist tracks are not promised no matter what any PD tells you *verbally*, these tracks only lengthen training anyways which clearly OP wants to avoid. You have to pay the price of admission if you want in

 

[Merely]

I would never do derm I'm exaggerating I didn't think you guys would be so sensitive on the internet...lol just saying it seems it could be 5 years so combined program would be nice option...jeez

 

[rokshana]

I would never do derm I'm exaggerating I didn't think you guys would be so sensitive on the internet...lol just saying it seems it could be 5 years so combined program would be nice option...jeez

Again, maybe you are better suited to go the PA/NP route...heck 2 years, no residency, and they think they are ready to do it all!

 

[Merely]

Again, maybe you are better suited to go the PA/NP route...heck 2 years, no residency, and they think they are ready to do it all!

I'm a third year medical student thats probably smarter than you were when you were at my stage of training...why are you telling me to become a nurse...lol

 

[gutonc]

I'm a third year medical student thats probably smarter than you were when you were at my stage of training...why are you telling me to become a nurse...lol

You must be fun at parties.

 

[rokshana]

I'm a third year medical student thats probably smarter than you were when you were at my stage of training...why are you telling me to become a nurse...lol

first the fact that you feel the need to assert your intelligence tells me that that is unlikely (the med studs that think they are smarter than their residents and attendings typically are the ones that end up crying by the end of the rotation), second your slightly above average Step I shows that is not the case (and ultimately may keep you from getting either derm or GI unless you impressively improve your CK, maybe psych would be easier to get) and third, your need to get to the money portion (since as a early in the year inexperienced 3rd year that would really be the only reason you would want to do GI AND not realize exactly how much medicine is actually involved in GI and most of your sdn history is pre-occupied with money) and not have to do the work to get there would be best suited to someone who wants to short track it and NP/PA is the best way to do that (but then there is the millennial aspect so, there is that)...

 

[rokshana]

You must be fun at parties.

you think he actually is invited to go to parties?

 

[JLC]

I can easily say as a first year GI fellow, that going into fellowship, doing IM residency was essential to make me competent. Think about it, first year fellows have nothing else but their IM residency behind them when they start fellowship. Furthermore, similar to other many other subspecialties, you need to be very well rounded to be a good GI doctor. You simply have not had enough exposure in GI to know that. Nobody can fault you if you are stupid. But you will be faulted for being ignorant. Go do a GI elective to learn more about the specialty before you think you know enough about it.

 

[Broponinelevation]

you think he actually is invited to go to parties?

Savage...

 

[Merely]

first the fact that you feel the need to assert your intelligence tells me that that is unlikely (the med studs that think they are smarter than their residents and attendings typically are the ones that end up crying by the end of the rotation), second your slightly above average Step I shows that is not the case (and ultimately may keep you from getting either derm or GI unless you impressively improve your CK, maybe psych would be easier to get) and third, your need to get to the money portion (since as a early in the year inexperienced 3rd year that would really be the only reason you would want to do GI AND not realize exactly how much medicine is actually involved in GI and most of your sdn history is pre-occupied with money) and not have to do the work to get there would be best suited to someone who wants to short track it and NP/PA is the best way to do that (but then there is the millennial aspect so, there is that)...

Your life must be pretty interesting that you actually took the time to search through my posting history...also I'm a usmd with a 245 step 1..you're right matching psych is my only option...you're pretty pathetic honestly hahahaha

 

[HoldTheCoffee]

Lol, kid's got a bad attitude, sure. But, he brings up a salient point in terms of the redundancy of medical education. The idea that you NEED 3 years of IM in order to do many of the subspecialties is just pure non-sense. Intern year is a must obviously, and you can make a reasonable argument for second year, but third year? Hell nah.

Honestly, you can make the same or even better argument for the redundancy of 90% of medical school for many of the surgical fields.

Hmm, I'm going to have to respectfully disagree. I went to a pretty good IM program and actually interviewed/was "accepted" for some fast-tracking positions but ultimately chose to go the full three years. I have to say, that third year really does make a difference and I'm glad I chose to go full categorial. My experience has been that being comfortable with IM translates very well to fellowship. To each their own I guess.

Your life must be pretty interesting that you actually took the time to search through my posting history...also I'm a usmd with a 245 step 1..you're right matching psych is my only option...you're pretty pathetic honestly hahahaha

OK dude, if you say so.

 

[DNM]

Despite the OP's attitude and some differences in our views -- this is something I have been wondering about and I wish we would at least start thinking about this kind of thing.

The recent advent of the liver year being built into traditional curriculum at a few places is a good start. For those of us looking at GI (and likely advanced training within that one day) the years spent starts to become a tall order. Between 3 years of residency, 3 for fellowship and then an ERCP/EUS year (possibly 2 years to get both if you're at a very academic place...) 7-8 years of post-graduate training seems to be insane. Can we really not trim some of the fat for those of us on the clinician-investigator track? Are we just going to keep adding years on as medicine becomes more complicated and people specialize further? At what point do these things start being their own field? (i.e. CT surg direct pathway vs general surg --> CT surg, or direct vascular surgery etc)

 

[CatFactorial]

Despite the OP's attitude and some differences in our views -- this is something I have been wondering about and I wish we would at least start thinking about this kind of thing.

The recent advent of the liver year being built into traditional curriculum at a few places is a good start. For those of us looking at GI (and likely advanced training within that one day) the years spent starts to become a tall order. Between 3 years of residency, 3 for fellowship and then an ERCP/EUS year (possibly 2 years to get both if you're at a very academic place...) 7-8 years of post-graduate training seems to be insane. Can we really not trim some of the fat for those of us on the clinician-investigator track? Are we just going to keep adding years on as medicine becomes more complicated and people specialize further? At what point do these things start being their own field? (i.e. CT surg direct pathway vs general surg --> CT surg, or direct vascular surgery etc)

What would you suggest trimming? Admittedly I am not a gastroenterologist, but as stated above, I think GI folks need a good command of both general internal medicine as well as sub specialty stuff. Endoscopists no less (hepatology included)

 

[Mad Jack]

That some bull**** though lol like why would they make it so that you're forced to go into something you don't really like in order to get something you want but have to risk being completely ****ed and being forced to stay in internal medicine?

Because IM residency separates the proverbial men from the boys and serves as a filter. There's also that whole "IM is the foundation of every subspecialty" thing.

 

[Mad Jack]

first the fact that you feel the need to assert your intelligence tells me that that is unlikely (the med studs that think they are smarter than their residents and attendings typically are the ones that end up crying by the end of the rotation), second your slightly above average Step I shows that is not the case (and ultimately may keep you from getting either derm or GI unless you impressively improve your CK, maybe psych would be easier to get) and third, your need to get to the money portion (since as a early in the year inexperienced 3rd year that would really be the only reason you would want to do GI AND not realize exactly how much medicine is actually involved in GI and most of your sdn history is pre-occupied with money) and not have to do the work to get there would be best suited to someone who wants to short track it and NP/PA is the best way to do that (but then there is the millennial aspect so, there is that)...

Psych tends to filter guys like this out.

 

[Merely]

Couldn't they have programs where you still do 3+3 but at least you're guaranteed a fellowship...that would probably take a lot of the stress out of things...and prevent you from being stuck in internal medicine hell and forced to be a hospitalist lol

 

[Broponinelevation]

it's kinda the whole point that nothing is guaranteed--requires you to work hard on every rotation during residency and know your stuff, as well as prove your competency to land those great fellowship opportunities. Also if you think IM other than GI is hell then that might make the whole going into IM thing a harder sell to residencies, just a thought.

 

[rokshana]

it's kinda the whole point that nothing is guaranteed--requires you to work hard on every rotation during residency and know your stuff, as well as prove your competency to land those great fellowship opportunities. Also if you think IM other than GI is hell then that might make the whole going into IM thing a harder sell to residencies, just a thought.

residencies are not having an issue with finding people...and GI fellowships are certainly not having an issue with finding people to fill their spots...and the lazy ones are easily noticed.

 

[CatFactorial]

Couldn't they have programs where you still do 3+3 but at least you're guaranteed a fellowship...that would probably take a lot of the stress out of things...and prevent you from being stuck in internal medicine hell and forced to be a hospitalist lol

What about the possibility of discovering over the course of your internal medicine residency that you wanted to go into cards, rheum, endocrine, general internal medicine (o the horror), or what have you? Lol. Because that NEVER happens, right?

Lol.

 

[rokshana]

Couldn't they have programs where you still do 3+3 but at least you're guaranteed a fellowship...that would probably take a lot of the stress out of things...and prevent you from being stuck in internal medicine hell and forced to be a hospitalist lol

maybe the less competitive fellowships would consider this, but those that have no issues in filling certainly won't feel the need to do this...why? they want to see proof that you will make a good fellow...as a med student, you are unproven...its like those BS/MD programs...

 

[CatFactorial]

Also, I don’t think this can be emphasized enough. GI requires a ton of knowledge. Infectious disease, oncology, rheum/autoimmunity, cards, pulm. Infratentorially, the liver is the black box of the body.

 

[Merely]

Yeah I see what you guys are saying it makes sense I just thought maybe it would be nice to streamline the process for those already knowing what they want but there are certainly pros and cons to the issue

 

[rokshana]

Yeah I see what you guys are saying it makes sense I just thought maybe it would be nice to streamline the process for those already knowing what they want but there are certainly pros and cons to the issue

that's just it though...very few in med school know what they will eventually end up doing...there was a study done a while back that states ~ 75% of 1st years end up changing their specialty by their 4th year...and even in residency things change...you get exposure to the specialty you think you want and realize its not all that you thought it would be...and get exposure to a specialty that you never though you would be interested in and love it!

sure there are those that have a significant background (they were a PA in the ED and now going to med school and plan on going into EM) and they don't waver...but i have far more examples of of classmates that changed their minds...a biochemical engineer major went to med school thinking optho, ended up doing GI...friend transferred from caribbean school to US school because he wanted to do orthopedics and ended up doing rad onc...i came in thinking ob/gyn to do REI and ended up IM to do Gen Endo (and toyed with Path and Radiology, and Nephrology along the way)...

 

[Merely]

that's just it though...very few in med school know what they will eventually end up doing...there was a study done a while back that states ~ 75% of 1st years end up changing their specialty by their 4th year...and even in residency things change...you get exposure to the specialty you think you want and realize its not all that you thought it would be...and get exposure to a specialty that you never though you would be interested in and love it!

sure there are those that have a significant background (they were a PA in the ED and now going to med school and plan on going into EM) and they don't waver...but i have far more examples of of classmates that changed their minds...a biochemical engineer major went to med school thinking optho, ended up doing GI...friend transferred from caribbean school to US school because he wanted to do orthopedics and ended up doing rad onc...i came in thinking ob/gyn to do REI and ended up IM to do Gen Endo (and toyed with Path and Radiology, and Nephrology along the way)...

True, thanks for the insights I learned a lot from this thread

 

[bronx43]

Despite the OP's attitude and some differences in our views -- this is something I have been wondering about and I wish we would at least start thinking about this kind of thing.

The recent advent of the liver year being built into traditional curriculum at a few places is a good start. For those of us looking at GI (and likely advanced training within that one day) the years spent starts to become a tall order. Between 3 years of residency, 3 for fellowship and then an ERCP/EUS year (possibly 2 years to get both if you're at a very academic place...) 7-8 years of post-graduate training seems to be insane. Can we really not trim some of the fat for those of us on the clinician-investigator track? Are we just going to keep adding years on as medicine becomes more complicated and people specialize further? At what point do these things start being their own field? (i.e. CT surg direct pathway vs general surg --> CT surg, or direct vascular surgery etc)

Well, sure. There will ALWAYS be people who think they extracted value out of additional training. You're one of them. I'm not one of them. Hell, I'm sure you would be better prepped to do whatever specialty if you trained in IM, general surgery, pathology, radiology, OB/GYN and dermatology. Why don't we just require all of those before pursing your end career?

I would argue that if you're able to pass the ABIM, then you probably have good enough grasp of IM to be able to perform your duties as a sub-specialist. In fact, I would say that few of the sub-specialists who have been practicing for 5+ years would I be confident to pass the IM boards if they took them now. That's not a knock on those people... it's simply a function of the human mind to focus on what you do on a day to day basis. I haven't been out of residency that long and I'm already very rusty on IM and have forgotten the nuances of diabetes management, which I was adept at as a resident. I can only imagine what would happen in another 5-10 years.

 

[DNM]

Well, sure. There will ALWAYS be people who think they extracted value out of additional training. You're one of them. I'm not one of them. Hell, I'm sure you would be better prepped to do whatever specialty if you trained in IM, general surgery, pathology, radiology, OB/GYN and dermatology. Why don't we just require all of those before pursing your end career?

I would argue that if you're able to pass the ABIM, then you probably have good enough grasp of IM to be able to perform your duties as a sub-specialist. In fact, I would say that few of the sub-specialists who have been practicing for 5+ years would I be confident to pass the IM boards if they took them now. That's not a knock on those people... it's simply a function of the human mind to focus on what you do on a day to day basis. I haven't been out of residency that long and I'm already very rusty on IM and have forgotten the nuances of diabetes management, which I was adept at as a resident. I can only imagine what would happen in another 5-10 years.

I don't know if you meant to reply to the posters who replied to me or what, but I think we are saying the same thing. You probably don't need to train as long as they have us train. People can say 'well you need to be a good internist to be a good specialist!', but I think that we can still shave off some fat. The specialists are generally not managing even basic medicine things (diabetes, hypertension, etc) at most places. When you specialize within your specialty, the chance that you are focusing on 'general internist stuff' is even less. Again, I maintain that you probably don't need 3 years of IM residency to be an ERCP guy.

I do wonder about a competency based approach as you mention. I've often heard from attendings that people generally become 'ready' for the next step as a 2nd year or 3rd year, depending on the person. For those who are at a good place during the end of 2nd year (possibly judge this based on ability to pass ABIM?), do they really need a 3rd year of medicine (often just filled with electives and reasonable inpatient rotations that probably aren't related to their field).

I would be interested to hear what some senior colleagues think about this (maybe @gutonc @Gastrapathy ?)

 

[ICmyFuture]

If you knew exactly what you wanted to do entering med school, ie imed sub-specialty, then I would say 3 yrs of MS, 2 yrs of gen IMED, then your specialty.

Not sure what 4th yr MS does for you other then a nice break before intern year. Also, 3rd year of residency makes you confident in gen IM but not sure it would help much for someone who is going to sub -specialize.

However, i dont see things changing for the foreseeable future.

 

[bronx43]

I don't know if you meant to reply to the posters who replied to me or what, but I think we are saying the same thing.

My bad, I quoted you in error. Meant to respond to the other poster.

 

[Gastrapathy]

I agree completely that it shouldn't take 10 years to grow a Gastroenterologist. IM has always opposed off-ramps because they would be so popular and provide even more incentive to subspecialize. I also think GI should still be 2 years with optional additional years for advanced, hepatology, etc. If I were building the system, Med School would be 3 years, IM 2-3, GI 2. The training creep is the inevitable consequence of training programs benefiting the most from senior learners.

A written exam is a poor measure of competency.

 

[CatFactorial]

Ha!

 

[bronx43]

I agree completely that it shouldn't take 10 years to grow a Gastroenterologist. IM has always opposed off-ramps because they would be so popular and provide even more incentive to subspecialize. I also think GI should still be 2 years with optional additional years for advanced, hepatology, etc. If I were building the system, Med School would be 3 years, IM 2-3, GI 2. The training creep is the inevitable consequence of training programs benefiting the most from senior learners.

A written exam is a poor measure of competency.

I would totally agree with this time line for medical education. I would also propose that medical school should also be tailored differently for those eventually going into surgery versus a medical specialty.

While a written exam is a poor measure of competency, the problem arises when one tries to come up with a reproducible, unbiased, standardized, and scalable measure of competency.

 

[rokshana]

so how would you deal with the logistics of completing board exams and applying for residency and fellowship? How would you have enough time to do rotations and research in the subspecialty to know that the sub specialty (or even specialty in terms of residency application) is what you want to do...if you decrease the time in 4th year of med school and 3rd yr of residency, then do you have the free time to accomplish these things.

the fact that there is decreased time in residency what with 80 hour work weeks and <24 hours for interns (which was probably more of a burden than a help) decreases exposure and education almost requires a longer time in training to achieve what residents before us did.

the timeline for applying for fellowships was pushed forward for a reason...applying in the middle of 2nd year just didn't give a resident enough time to build a decent CV for application to a subspecialty...

 

[bronx43]

so how would you deal with the logistics of completing board exams and applying for residency and fellowship? How would you have enough time to do rotations and research in the subspecialty to know that the sub specialty (or even specialty in terms of residency application) is what you want to do...if you decrease the time in 4th year of med school and 3rd yr of residency, then do you have the free time to accomplish these things.

the fact that there is decreased time in residency what with 80 hour work weeks and <24 hours for interns (which was probably more of a burden than a help) decreases exposure and education almost requires a longer time in training to achieve what residents before us did.

the timeline for applying for fellowships was pushed forward for a reason...applying in the middle of 2nd year just didn't give a resident enough time to build a decent CV for application to a subspecialty...

Why wouldn't you have enough time? In medical school, you can definitely compress the first two years' curriculum into 1.5 years, and start rotations then. Then you do your core rotations for one year, and then apply to your specialty at 2.5 years. It doesn't take a whole year to apply and interview... the fact that the process is dragged out so long is a joke. In fact, Duke was able to compress their 1st and 2nd years into 1 year, and their students start clinical rotations second year.

In terms of residency, I would propose that if you are specializing, the third year should be optional. If you want to further round out your medicine skills then you can complete the third year. Otherwise, one should be allowed to apply for fellowship 2nd year, and sit for the boards the year after.

 

[Anicetus]

True, thanks for the insights I learned a lot from this thread

Hey I remember you from years ago. I agree it sucks that we need 3 years of IM and when I was an MS3 this was originally the reason I gave up on GI at first. I also heard of people being stuck as a hospitalist when they couldn't get into GI. However by the end of third year, I realized I was willing to take the risk over the other specialties. When the AI rolled around I ended up loving IM as well - weird cuz I hated third year IM. I will say to keep in mind that no matter how smart or good someone is in IM, GI isn't guaranteed so think deeply about the possibility of doing IM as a career and living with it or another fellowship before making the commitment at first.

 

[jdh71]

From where I'm sitting 3 + 3 is the right amount for pulmonary and critical care. I can see how others because they use much much less of internal medicine (usually on purpose) to take care of patients think the process should be shorter and or focused. The less training and experience of my colleagues will cut both ways pretty hard for someone like me. It will mean I'll have to deal with more of the heavy lifting and moral hazard of other specialists because they no longer can (admitting every sickly chemo patient, or every GI bleeder, or every heart attack). Hell even now probably 10-15% of my work is "super-hospitalist" crap because those guys can't deal or hang. It *should* mean more money for me but working for every thin red cent of that may get really really old aggravating.

I guess I'd simply like to see better clinicians. I see too much feigning ignorance crap and too much laziness. Maybe the path to better clinicians is more lazer focus? I guess I might be open to that especially if it might make folks more thoughtful. (I can't hope for my caring. You either have that or don't. Some find it later I guess.). But from where I'm sitting I think less time in training would lead to even more folks who have literally no clue what to do too often. That's bad for patients and a moral hazard to colleagues.

 

[DNM]

From where I'm sitting 3 + 3 is the right amount for pulmonary and critical care. I can see how others because they use much much less of internal medicine (usually on purpose) to take care of patients think the process should be shorter and or focused. The less training and experience of my colleagues will cut both ways pretty hard for someone like me. It will mean I'll have to deal with more of the heavy lifting and moral hazard of other specialists because they no longer can (admitting every sickly chemo patient, or every GI bleeder, or every heart attack). Hell even now probably 10-15% of my work is "super-hospitalist" crap because those guys can't deal or hang. It *should* mean more money for me but working for every thin red cent of that may get really really old aggravating.

I guess I'd simply like to see better clinicians. I see too much feigning ignorance crap and too much laziness. Maybe the path to better clinicians is more lazer focus? I guess I might be open to that especially if it might make folks more thoughtful. (I can't hope for my caring. You either have that or don't. Some find it later I guess.). But from where I'm sitting I think less time in training would lead to even more folks who have literally no clue what to do too often. That's bad for patients and a moral hazard to colleagues.

Thanks for the thoughtful response. I definitely see a lot of merit with your points. I think rather than shortening the traditional 3+3 we have now, I'm more frustrated by the continual training creep and time associated with specializing after you've already specialized. I am passionate about ERCP, but the idea of being a PGY-7 (or at some places that don't let you get EUS in the same year) is a tall order. Striking a balance between training length and competency is definitely a challenge and I doubt things will improve any time soon.

 

[jdh71]

Thanks for the thoughtful response. I definitely see a lot of merit with your points. I think rather than shortening the traditional 3+3 we have now, I'm more frustrated by the continual training creep and time associated with specializing after you've already specialized. I am passionate about ERCP, but the idea of being a PGY-7 (or at some places that don't let you get EUS in the same year) is a tall order. Striking a balance between training length and competency is definitely a challenge and I doubt things will improve any time soon.

Yeah it's the same with interventional pulmonary. Though EBUS is something being picked up at least by some coming out of fellowship (but not so much a lot of the other stuff done by IP). But there is something to be said for spending a whole year doing nothing but advanced scope. Procedures have the devil in their complications and nonstandard approaches in certain cases. I would argue the BEST way to see these types of issues is under the tutelage of an experienced operator.

I think training creep is a product of how much more complicated and nuanced medicine is getting and I'm not convinced there is a good way around adding time if we actually want well rounded competent physicians.

I might be a masochist and hate myself though.

 

[gutonc]

I think training creep is a product of how much more complicated and nuanced medicine is getting and I'm not convinced there is a good way around adding time if we actually want well rounded competent physicians.

I might be a masochist and hate myself though.

I think this is the major issue, especially in procedural specialties. IP stuff outside of EBUS (stents and cryo and s**t), EMR and other advanced endoscopy, TAVR and peripheral vascular...all that needs more training, there's just no way around it. And you need the base (bronch, EGD, cath) experience to even get to the advanced stuff. So I suspect that these sub-specialties will continue to have increased training requirements.

And the hell of it is, one could easily argue that PCCM, GI and Cards are specialties that require an extremely solid IM base in order to do well. I think the analogies to the integrated surgery programs is a flawed one. If you're doing an integrated vascular program, you can just focus on the tubes with the blood in them and forget the rest. Integrated CT surg? Anything above the clavicle and below the diaphragm doesn't exist. Integrated plastics? If you can't see it in the exam room, it doesn't matter. Advanced training in cards, GI and PCCM doesn't have that luxury.

 

[bronx43]

I think this is the major issue, especially in procedural specialties. IP stuff outside of EBUS (stents and cryo and s**t), EMR and other advanced endoscopy, TAVR and peripheral vascular...all that needs more training, there's just no way around it. And you need the base (bronch, EGD, cath) experience to even get to the advanced stuff. So I suspect that these sub-specialties will continue to have increased training requirements.

And the hell of it is, one could easily argue that PCCM, GI and Cards are specialties that require an extremely solid IM base in order to do well. I think the analogies to the integrated surgery programs is a flawed one. If you're doing an integrated vascular program, you can just focus on the tubes with the blood in them and forget the rest. Integrated CT surg? Anything above the clavicle and below the diaphragm doesn't exist. Integrated plastics? If you can't see it in the exam room, it doesn't matter. Advanced training in cards, GI and PCCM doesn't have that luxury.

I agree that PCCM doesn't have that luxury, since it's basically medicine on pharmaceutical grade cocaine. You cannot have a good pulm/CC doc without a good internist.

However, for the more sub-specialized proceduralists, that argument gets a lot more muddy. For example, what does an EP cardiologist know about DM management or work up for AKI or differential diagnosis for chronic low back pain? I mean, sure they have to know to tell the pharmacist to renally dose their antiarrhythmics or the internist to optimize blood sugars, but that doesn't exactly take any extensive knowledge of the subject. Again, I don't think anyone is arguing that an EP should skip IM altogether, but it certainly doesn't take 3 years and board certification in it...
My institution has one of the most prolific and renowned EP groups in the country, and they are basically as well versed in medicine as our orthopedic residents. Not even joking.

 

[Kakoy]

I agree that PCCM doesn't have that luxury, since it's basically medicine on pharmaceutical grade cocaine. You cannot have a good pulm/CC doc without a good internist.

However, for the more sub-specialized proceduralists, that argument gets a lot more muddy. For example, what does an EP cardiologist know about DM management or work up for AKI or differential diagnosis for chronic low back pain? I mean, sure they have to know to tell the pharmacist to renally dose their antiarrhythmics or the internist to optimize blood sugars, but that doesn't exactly take any extensive knowledge of the subject. Again, I don't think anyone is arguing that an EP should skip IM altogether, but it certainly doesn't take 3 years and board certification in it...
My institution has one of the most prolific and renowned EP groups in the country, and they are basically as well versed in medicine as our orthopedic residents. Not even joking.

i completely believe it. Back in residency, we had a awesome EP attending ( I have the biggest attending crush on her) who was covering the cardiology stepdown floor team. We were discussing a new admission and a pt came in on metformin. She was like.... is that med for copd? I swear, my interns jaw dropped. At least she remember it was use for common medical conditions.

 

[Southplains]

i completely believe it. Back in residency, we had a awesome EP attending ( I have the biggest attending crush on her) who was covering the cardiology stepdown floor team. We were discussing a new admission and a pt came in on metformin. She was like.... is that med for copd? I swear, my interns jaw dropped. At least she remember it was use for common medical conditions.

I can see this being the exception not the rule but my experience was very different in M3 and M4 rotations with cardiology. They would constantly rip apart the residents for practicing poor IM, repeatedly stressed to me the importance of being a good internist first and foremost, and I remember being pimped on scleroderma after a peripheral cath one day.

Also their notes were the most comprehensive and perfect notes I ever saw consistently through clinicals. Really looked up to those guys.

 

[bronx43]

I can see this being the exception not the rule but my experience was very different in M3 and M4 rotations with cardiology. They would constantly rip apart the residents for practicing poor IM, repeatedly stressed to me the importance of being a good internist first and foremost, and I remember being pimped on scleroderma after a peripheral cath one day.

Also their notes were the most comprehensive and perfect notes I ever saw consistently through clinicals. Really looked up to those guys.

Pimping you on scleroderma? LMAO. Yeah... pretty sure that's the exception and not the rule. Also, general cardiology is not the same as a procedural sub-specialty like EP. Not even close. I can see how general cards can write acceptable notes, since SOME of what they practice is IM.